Improving Transitions of Care from Inpatient to Outpatient Behavioral

Health Settings

June 30, 2016

TCPI Change Package: Drivers Addressed

•1.1 Patient and family engagement

•1.3 Population management

•1.4 Practice as a community partner

•1.5 Coordinated care delivery

•1.6 Organized, evidence-based care

•1.7 Enhanced access

1. Person and Family-Centered Care Design

•2.1 Engaged and committed leadership2. Continuous, Data-Driven

Quality Improvement

•3.4 Efficiency of operation3. Sustainable Business

Operations

Psychologist,

Department of Psychiatry

Stacey Blase, PhD

Manager of Clinical Services,

Emergency and Inpatient Psychiatry

Ana Valentin, LCSW

Program Director,

Care Transitions Network

Trisha Blackburn, LCSW

Senior Executive Director,

University Behavioral Associates

Johnine Cummings, LCSW

Associate Director,

University Behavioral Associates

Bill Woolis, LCSW

1. Why transitions of care matter

2. Challenges to successful transitions of care

3. Interventions and strategies for improving care transitions

Overview & Roadmap

• Transitions from points of care pose substantial obstacles to successful treatment outcomes

• Inpatient to outpatient transitions are particularly problematic from an individual, health system, and societal perspective

• Significant risks include care disengagement, symptom exacerbation, and hospital readmissions

Why Focus on Transitions of Care?

Behavioral Health Readmissions

7 days

30 days

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Post-DischargeOutpatient

AppointmentsKept

30 days

90 days

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

ReadmissionRates

New York State Behavioral Health Organization Performance Metrics Statewide and Regional Report, Calendar Year 2010 & 2013

Statewide Perspective on Readmissions and Outpatient Appointments Kept

• Mutual interests between provider organizations and the MCOs• MCOs highly invested in the time period between inpatient and outpatient

• MCOs now responsible for the larger spectrum of BH care

• Seeing MCOs as a resource• Bank of information on your patients’ histories of care

• Increased number of people in Managed Care now = greater wealth of information held by the MCOs

• Moving to value-based payment means rethinking this relationship• MCOs expected to assess quality of providers based on outcomes and

patterns rather than individual case utilization review

Collaborating with Managed Care Organizations

• Lack of client participation in creation of discharge plan

• Lack of client engagement in recovery process

• Confusion / disagreement about discharge plan

• Early stages of treatment acceptance

• Lack of family support/engagement in recovery

• Delay between discharge and appointment

• Logistical barriers to accessing services

• Difficulty reaching patient after discharge

• Stigma

Barriers to Successful Transitions of Care

Interventions to Improve Transitions of Care

care manager

outpatient

family

hospital

Inpatient Admission Assessment

• Identify readmissions / high utilizers

• Conduct in depth review

• Why were they readmitted (root causes)?

• What can we do differently this time?

• What was the last discharge plan? How well did it work?

• Review in treatment team meeting, cross department meetings (ER, inpatient, case workers, outpatient)

• Integrate dual diagnosis treatment: identify and treat, refer to providers of integrated treatment for aftercare

Assessment

Involve Family & Support System

• Support evaluation

• Assess family needs

• Provide crisis intervention

• Psychoeducation and skill-building• “what do you think needs to happen to keep patient out of the hospital?”

Family & Support

Planning for Aftercare

• Follow-up appointment with aftercare mental health provider within 5 days of discharge

• Use higher-intensity outpatient services for hospital diversion and hospital step-down

• Partial Hospitalization Program (PHP)

• Some clinics developing Intensive Outpatient (IOP) level of care

• Crisis Respite

• Identify and coordinate with existing community support services (ACT, Health Home, other Care Management, MCOs)

Planning

After Hospital Care Plan

• Develop and use After Hospital Care Plan

• Provide discharge instructions, including

1. Clear medication instructions

2. Follow-up appointments (arranged before discharge)

3. Clear, easy-to-understand care plan with name and number to call with any problems

• Educate client and family using teach-back methods throughout inpatient stay

Discharge Plan

What makes a discharge plan successful

• Focuses on strengths and on hope for recovery

• Provides useful information that is responsive to what is important to the client

• Provides self care and self management support tools

• Patient agrees with discharge plan

Person Centered Plan

Qualities of a Person Centered Plan

• Based on client-identified, personally meaningful goals

• Blends formal and informal supports

• Provides long term goals broken down into short term action steps

Bridging and “Warm Hand-offs”

• Face to face meeting with receiving outpatient provider during inpatient stay or immediately upon discharge• Discharge planning meeting: outpatient provider,

client, family, and inpatient team

• Individual meeting/session: outpatient provider and client

• Build / practice / test skills that will help patient succeed in the next lower level of care

• Wellness Recovery Action Plan (WRAP)

Bridging

Follow-Up Phone Calls

• Follow-up phone call to client/caregiver within 72 hours• Clinical intervention / engagement (not just a reminder)

• Use teach-back method

• Project RED Key Components1. Assess clinical status

2. Review and confirm each medication

3. Review follow-up appointments

4. Assess for barriers, problem-solve, review what to do if problem arises

5. After call: any needed follow-up actions

• Follow-up phone call to provider

Follow-Up

Short-Term Case Management

• May be provided by case manager, bridger, peer, etc. who can actively follow up on non-adherence to discharge plan

• Key principles• Assess client risk, adjust intensity and time frame accordingly

• Address concrete needs, especially those that will pose barriers to accessing medication and aftercare services

• Include home visits if necessary

• Actively follow up on non-adherence (e.g. reschedule missed appointments)

• Some resources to consider: MCOs, Health Homes, etc.

Case Management

• Identify and flag clients referred from inpatient

• Reminder phone calls before first post-hospital appointment

• Follow up on non-attendance

• Develop strategies for crisis management• relapse prevention plans with monitoring for early

warning signs

• urgent care / walk-in appointments and on call availability

• Develop crisis plan

• Offer specific resources for follow-up care other than the ER• Crisis Respite

OutpatientManagement

Community Partners

• Know/engage community partners across continuum of care• Standardize communication

• Develop protocols for expedited referrals

• Collaboration on treatment and discharge planning

• Develop a relationship with at least one pharmacy

• Real-time communication between inpatient & outpatient

Collaboration across the Continuum of Care

Identify a portfolio of mutually reinforcing interventions across the care continuum, make ongoing incremental change

• Start with root cause analysis of readmissions

• Track clients, interventions, and outcomes over time (CQI)

• Develop committee on care transitions to facilitate collaboration and streamline processes• Buy-in / Motivation

• Education

• Resource Allocation

No “silver bullet”

Thank you!www.CareTransitionsNetwork.org

CareTransitions@TheNationalCouncil.org

The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.